S 0154 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT RICA PEj`4uT NO
BUII,DING DIVISION APPLIC/11'IONIPERMIT PLUMBING-MECHANICAL �J 0154
BUILDING PROJECT IDEN'T'IFICATION
BUILDINGADDRESS: SANITARY NO. APPUCAI'[OON SUBMITTAL DATE
$(5�O P,� ells-I -A Cl f L . — l 3
I OWNERIS NAME PHONE: y$5—Z 'ONTRAC'IOlk yi NAME LIC NO:
1•.kIZ.� µ(Zs �--' skL 4 tL.a-,1 t- S.Sa./ sear N/C corrrRDl.x
ARCHITECT/ENGINEER: LIC NO: ADDRESSlar : ❑
(pQp L=jr_4uv!x SuNaF.ayV.��
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLOC F.ECT' PLUMB MUCH
LICENSEDCONTRACI'OH;SDECLARA'rION QTY. ELECTRIC PERMIT FEE ❑
CWZI heresy d1hun mm Iran licensed under provisions of chapter 9¢atnouracirg JOB DESCRIPTION
with Section 7 )ofDivinion3ofde Busineasanllsofiosi...Coda ralmylienewis PERMIT'ISSUANCE RESIDENTIAL:
I-,- P0in fullforecandc t.
-4o
❑SFDWL ❑KITCHEN REM
ODEL
VLiceaClass Lic.a6U APPLIANCES-RESIDINf1AL ❑ADDITION ❑PLUMNING REPIPi
PGLData m Jd L�Contmc(or� ❑MULT-UNIT ❑STRUM GRAL
AIiPANELS
MODIPICAI'ION
Z O r^z I understand my plane shall M used as public records
OZNO UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F�Fu] Licensed Profes,mml 201-10x0AMPS IMPROVEMENT EJ SWIMMING POOLS
G �"t OWNER-BUILDER DECLARATION
4etiowu K CC 6 1 hereby alYlnn'he,I inn camnP(from the GsmmcmKu license Law Latina OVER 1000AMPS EI DATH REMODIiIAREPAIR DEMOLITION
yKj 3�F fallowing maws(Section 7031.5.Business and Pmfrssirrm Cade Any city or county SIGNS ELECTRICAL [I OTHER
y which its issuance,
ssn permit to Wres the
aper,improve,demolish or repair any swnum
poor to
lintheslicarnncanHorn India
mvPkivUcant thc wchrach in Ucrro file ac signedstatementSPECIAL CIRCUIT/MISC.
'�,y, y non he ivliwmulpnrsm(roto(nepmviaior.anneGimmamrsLkanaeLnw(cnapmry
�...G�O (mmntencing with Section 70XRUI One...m3m mUBusiness nnJ Professinre Ctde)nr TEM('.MI?'CER OR YI)LIi IN ST. COMMERCIAL
dao IY that he is exempt therefrom and the basis for the alleged exemption.Any viol.in
of ❑NEW BLDG/ADDITION ❑DEMOLITION
�m S<ction7031.5byany applicant for a permit subjects he applicant to n civil Penalty of POWER DEVICES ❑TENANT FOOD SERVICE
not mare than fee hundred dollars($500). IMPROVEMENT
^ 0 ❑ L vsnwnernf the property,Lou,employees with wugc,as lheirsole compcnsntlnn, SWIMMING POOL ELECTRIC
Sec will Jn the work,unJ themmcure is nm imenJcJ nndfcred for sole lSec.11H4,Rosiness ❑OTIiF.R
u]3 m and I'tnfessionc Cents The Contractor's License Law does not apply m an aware of OUT1.E'LS—SWITCIIIS—FI%TURCS
pmKny who builds or improves thereon,and who does such work himself or through
his own employees,providW that.such improvements are not intended cr olfeard for NEW RESIDENUHAI.ELECTR SQ t1's
sale.11.however,the building or intprovcmen('n sold within one year cnmorrima0c SQ.IT.1401 A .A $ISQ.FT.
owner-builder will have the burden of pno ing(lint he did not bodd or improve for x L: Ia'N(Iper- AUG W ga��a
poof sale.). TOTAL
Fl 1.as owner of the property,am exclusively contracting with licensed contractors to r aaVylVl l/
consumer the project(Sec.70W,Business and PrnfeWons Code:)The Contractor's Li-
o,Law does inn apply man owner or property who mild%or impravcs meman,and QTY. PI. PERMIT FRE rid�Y {jr L,UN
who convects for such projects with.conwm..fit licensed pursuant o the Contractor's
License law. PERMIT IS5UAffC11
D I um exempt under Sec. .B&P C for this¢ams
ALTER—DRAIN&V. —W H I VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROD: .V
In rcby alfrm under penalty of pc jury one of the following Jeclamtione
I have and willm ."Int.aCadificate of Consent to df-insert for Workds Compcn- DRAINS—FLOOR.ROOF,A A. )N STORIES TYI'f:CONSTRUCTION
�m,as provided for by Section 3](01 of the Labor Cola for the performance of The
-
k for which this permit is is.old FIXTURES—PER TRAP
❑I have and will nmimain Worker's Compensation Insumnre,an required by Section
3708ofthe Tabor Code.for the pedrmerecof the work for wh ndinspermit ismtand, GAS—EA.SYSTEM-1 INC.J OUTLETS OCC.GROUP APN
My Workt!.2ZPpenw Inwmn Ureteral Policy ta�
Carrier: �a'�`—' �=ff Policy No.AN kTL0t a< GAS—IiA.SYSTEM-OVER 4 BDG
CERTIFICATE OFEXE:MPPION FROM WORKERS' GREASE]INDUSTRI,WAS Ui IN'I'ERCEMOR
COMPENSATION INSURANCE BUILDING DIVISION PliliS
(Thnsec(ion recd nm M completed if(he permit is foram hundred dollen PilOB) GREASETRAP
or less.) PLANCHFLK ITE
I readily that in the performance ofthe work rorwhich this permit is issued,I shall SEWER—SANITARY—STORM BA.200 FT.
not could,any at t onyn, nerve,sato Mmmc sunjucno ire Wnrkcrd Cnmpen- ENERGY FET?
Z ofon laws of Cidlom e.Dom WATER HEATER N'/VEiNT/ELIiCI'H
ZApplicant Q GRADING FEE
y NOTICE TO APPLICANT:If,nfmr making this Certificate of Exemption,you should WATEiR SYSTEM,rREiATING
Masmc subject to the Worker's Compensation provisions of the Labor Code.you most SOILS FEE
f nhwith comply with such pno,kior sor his panni(shall he deemed revoked. WATER S12RVICE
LLLL=IIz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL('LMB. SQ.FL PAID
I hemby vRrm tnauhem isacnnstme(ion lending agency Tonle perinnnance of Date Receipt#
W � permit the work for which this is issued(Sec.3017,Civ.C.) TOTAI:
O Lender's Name gUlAh
UU Lenders Address .
I eedify that I have mad this application and state that the above information is BUILDING Bili
f` N comet.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U z huildln,car,rande.,mallu eby amborlm mpresentativesofdo,city to eater upon the
nbovomentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC hili
(We)a,.to save,indermady and kacp females,the City of co'ninn agaivl
lab ili(ies.juit ems.costs and expenses which may in any way accrue against Said City AIXER OR ADD TO MECH, PLUMBING DHE
amwyu<nc d c stirs&of this p�mtir.
APPLICANT ' ri� Ile
TANDS A fU WILL COMPLY WITH ALL NON-POINT AIRTIANULINGUNT'f('ro H1.INx)TEM) MECHANICAI,FFE
SOIJI(CF,RE L NS.
6 A � AIR HANDLING UNIT LOVER 10L(NX)CFM) CONSTRUCTION TAX
Signawre of
of D,se EXHAUST HOOD(W/DUCT) HOUSING MI'T'IGATION ETT
e IA OUS MATERIALS DISCLOSURE
Wills app not nrobmahm1in&ncaefamsrore or boodle ha,aul snmonist I IP.ATINO ON IT(TO I(RI.0m IT Of
as defined by the C pen to Municipal Code,Chapter 9.12,end the Health and Safety
Gds Section 2553 ap HEATING UNIT(OVER 1010 0 BTU)
0Yo ❑No VENTILATION PAN(SINGLE RESID) I'AIU
Dam Rcacir(x
Will the applicant or future building occupant use equipment lir de,J,as which BOILER—COMP(?IIP OR Initial)BTU)
emit hamrdous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
Dionn' BOILER—COMP(OVER ELLEN)BTU)
❑Yes ITT No
I have rcud the th volusntaterials re is under Chvtcr h95al'the Cab- AIR CONDITIONI!R 2•S 'TC.S�.1 ISSUANCE DATE
uimman
non IT
in
Code,.11 I tats 25505,255A and 255?J.I understand that B the NIiW RESIDENTIAL MECH. SV.PI'.
building does not currently have a Comm'ded it is my respovibility m tmtify the rccupam
of the rairementa which mus(M me panne m Ecsvanee of a Certificate of Occupancy.
Owner or authcrvird agent Unto TOTAL: ISSUED BY:
OFFICE